With the passage of the Healthy, Hunger-Free Kids Act, the United States Department of Agriculture will be revising the nutrition guidelines for the Child and Adult Care Food Program for the first time in decades. This represents an important time to align the program with the current Dietary Guidelines for Americans and to address the epidemic of childhood obesity that has developed over the past several decades. CACFP is a federal nutrition assistance program administered by the Food and Nutrition Service of the USDA. According to the USDA, CACFP serves meals and snacks to 3.2 million children every day who are in participating child care centers, Head Start Programs, afterschool care programs and family and group day care homes.

In 2010, the Institute of Medicine’s Committee to Review CACFP Meal Requirements, convened at the behest of the USDA, conducted a study to review current CACFP meal requirements and recommend revisions to these requirements to bring them in-line with current dietary recommendations. Among the findings in this report was that there is presently a dearth of information related to CACFP, including lack of data on participants and their dietary behaviors as well as other program outcomes.

To address this information gap, the IOM Committee recommended that the USDA support research in three primary areas: conduct of baseline data collection on food and nutrient intakes by program participants before revised CACFP guidelines are implemented; assess factors that could influence the impact of the regulations; and evaluate the impact of the program on the types of foods eaten by participants and on the nutritional value of those foods (1, 2). This recommendation for research was incorporated into the final HHFKA legislation.

As part of the HHFKA, the USDA is required to conduct a $5 million study of nutrition and wellness quality in child care settings. Specifically, they will conduct a nationally representative study to assess the nutrition quality of all foods provided to children in child care settings as compared to the Dietary Guidelines for Americans; the quantity and types of physical activity provided to children in child care; the quantity of time children in child care spend in sedentary activity; and an assessment of facilitators and barriers to providing healthy foods and opportunities for physical activity to children in child care. While the CACFP is primarily focused on provision of healthy meals and snacks to children, providers who participate in CACFP can contribute positively to reducing sedentary and screen time and encouraging physical activity, one of the more recent additions to the Dietary Guidelines for Americans.

While the specific design and methods of the $5 million study have yet to be determined, planning is already underway. On February 7, 2012, the IOM hosted a one-day workshop at the request of USDA to discuss best practices and promising methods for data collection. Although the study must address multiple categories, including physical activity and sedentary time, the workshop focused primarily on nutrition. 

Four key needs to consider while developing the study were outlined during the workshop. First, the evaluation design needs to be sufficiently robust to collect the required data but not be overly burdensome on child care providers and families. Second, the providers and observers who will conduct data collection activities will need training to ensure that the data is collected using valid and reliable methods. Third, the evaluation design must take the unique characteristics of family day care homes into consideration. The fourth need, that the study should consider the importance of measuring physical activity and screen time along with nutrition, was touched upon but was not the focus of the workshop. Above all, it was clear that collecting data from a nationally representative sample of child care facilities would present unique challenges. For example, many of the most precise ways of measuring the amounts of foods served and eaten, such as measuring plate waste and direct observation, are labor-intensive and costly (3). Less intensive methods, such as menu reviews, do not always collect data on portion sizes and can’t provide information about the actual foods and nutrients consumed by the children (4,5,6,7). Also, unlike schools, which often have central kitchens, sophisticated menu planning, and highly-trained staff, child care facilities—particularly family day care homes which represent 73 percent of CACFP sites—lack standardized practices and training on nutrition, physical activity and data collection methods.

When considering the breadth and depth of research needs for CACFP, as well as the challenges inherent in the data collection, one can imagine $5 million being spent very quickly. Yet, it is important that all aspects of the legislation are addressed to obtain a true picture of the impact of this important policy change. We know that early childhood is a critical period for healthy growth and research demonstrates its importance in the epidemiology of obesity. We also know that outside of the home, child care settings are the most common environments where young children spend their days. As such, this study will be extremely important for determining the impact of this policy change on children, as well as for assessing what is currently happening in child care settings where many U.S. children are spending considerable proportions of their days.

There are two areas of focus that we hope will figure prominently in the final study design:

Importance of Studying Family Day Care Homes
As noted above, family day care homes comprise 73 percent of CACFP-participating facilities; however, very little is known about the dietary behaviors of young children being cared for in family day care homes and considerable research is needed. A 2011 literature review and research policy paper on the role of child care settings in obesity prevention found no interventions had been designed for these settings (8) and only one study included a large sample of family child care providers (9).

Family child care homes are not like schools or like larger child care centers; these providers frequently care for children of multiple age groups and often have no support staff like assistants, cooks, or dietitians. Family child care providers also do not generally receive the same level of training as other child care providers and have limited time to help researchers collect data. Of the data collection methodologies discussed in the IOM workshop, very few have been used in family day care homes—the tools and instruments have generally been designed for, and validated in, child care centers (10, 11, 12). Despite these challenges, research in this area to assess current practices of the nearly 2 million children cared for in these settings (13) would fill an important gap and the proposed study is a valuable opportunity to learn more about this area.

To help advance research on family day care homes, Altarum’s Center for Healthy Child and Youth Development is partnering with the New York State Department of Health to evaluate one of the first childhood obesity interventions in the country targeted at the family day care home environment: Eat Well, Play Hard in Day Care Homes. The primary goal of the intervention is to improve family day care home environments and practices related to healthy eating, physical activity, and screen time in order to prevent obesity among young children. It is designed as a 12-month intervention where providers receive intensive group training on healthy practices, as well as in-home, one-on-one training and technical assistance from a registered dietitian. Booster lessons are used to extend learning and reinforce messages throughout the intervention period. The program also teaches providers how to engage parents in healthy eating and physical activity for their child.

The Eat Well, Play Hard in Day Care Homes intervention will be piloted in six cycles between late 2011 and 2013, and will engage approximately 192 home day care providers. Day care home recruitment will be targeted at providers serving low-income children in high-need areas in four counties in New York. There is great potential to learn about what works in family day care homes and to develop effective and sustainable models for state and national dissemination. Altarum Institute will use a mixed methods approach to learn how the intervention is implemented, perceived, adopted and used by providers, as well as whether changes in practices and environments translate to improved healthy eating and activity behaviors by children and families. The results from this evaluation will inform the field by providing new knowledge about how obesity prevention interventions translate in family child care settings and how they can be designed to be most effective.

Importance of Physical Activity and Screen Time
Although the IOM workshop focused on nutrition standards, it is important that the eventual study fulfill the legislative requirements to research questions about screen time and physical activity. Physical activity is an important component of children’s healthy growth and development and participating in adequate amounts of physical activity is associated with lower rates of childhood obesity. Sedentary activities, such as screen time, are associated with higher rates of obesity among children. Because these behaviors are integral components of health and weight status, it is important to ensure that they are adequately and accurately assessed through this study, and are not afterthoughts to a nutrition research study. This is consistent with the language of the legislation and will provide important information to this field of study.

In the coming months and years, the USDA and early childhood development stakeholders across the nation will be working to determine the most efficient and effective ways to gather the robust data needed to assess the impact of the changes to the CACFP. Ongoing experiments in child care settings at the state level, such as New York’s Eat Well, Play Hard in Day Care Homes project, can continuously inform the process of shaping this evaluation and provide best practices and models for implementation and evaluation. It will take careful and wise use of the very limited funding to carry out this deeply needed and important research to help ensure that child care environments are healthy.

References

1. Institute of Medicine of the National Academies. (November 2010). Child and Adult Care Food Program Aligning Dietary Guidance for All. Report Brief. Institute of Medicine of the National Academies: Washington, DC.

2. Institute of Medicine of the National Academies. (November 2010). Child and Adult Care Food Program Aligning Dietary Guidance for All. Institute of Medicine of the National Academies: Washington, DC.

3. Ward, DS. (February 2012). How to Assess Food Served in Child Care Settings. [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

4. Ward, DS. (February 2012). How to Assess Food Served in Child Care Settings. [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

5. Fox, MK. (February 2012). Adapting Methodology from the SNDA and FITS Studies to Assess the CACFP [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

6. Neelon, SB. (February 2012). Dietary Assessment in Young Children: Total Daily Intake of Food and Nutrients. [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

7. Dixon, B. (February 2012). Analysis of Dietary Data Collected from Childcare Settings [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx
8. Larson, N., Ward, D.S., Benjamin Neelon, S., Story, M. (2011). What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. Journal of the American Dietetic Association, 111,1343-1362.

9. Trost, S.G., Messner, L., Fitzgerald, K., Roth, B. (2009). Nutrition and physical activity policies and practices in family child care homes. American Journal of Preventive Medicine, 37, 537-540.

10. Ward, DS. (February 2012). How to Assess Food Served in Child Care Settings. [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

11. Fox, MK. (February 2012). Adapting Methodology from the SNDA and FITS Studies to Assess the CACFP [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

12. Neelon, SB. (February 2012). Dietary Assessment in Young Children: Total Daily Intake of Food and Nutrients. [PowerPoint Slides]. Presented at the Review of the Child and Adult Care Food Program: Future Research Needs Workshop, Washington, DC. Retrieved from: http://www.iom.edu/Activities/Nutrition/ChildAdultCareFood/2012-FEB-07.aspx

13. Bell L, Mantinan K, Moore J, & Perosino K. (February 2012). Recommendations for Improving Nutrition and Physical Activity among Children and Families. Prepared for the Bipartisan Policy Center’s Nutrition and Physical Activity Initiative. Altarum Institute: Washington, DC.